Each year, an estimated 65,000 deaths occur in the US due to vaccine- preventable diseases of which more than 30,000 are preventable by immunization. In 1995 only 58% and 36% of persons 65 years of age or older reported receiving influenza and pneumococcal vaccines, respectively and rates were even lower for certain influenza immunization levels to at least 60% is unlikely to be achieved. Why are immunization rates for adults so low? Why are pro-active systems used so little, given that the literature shows that they are effective in raising rates? In the first phase of this study, the primary barriers to influenza and pneumococcal vaccination and to use of pro-active systems will be identified by an in depth study in a diverse group of settings including Veterans Administration clinics (one of which uses pro-active systems), inner city neighborhood clinics, and a set of primary care practices. To do this, a multi-disciplinary team with qualitative expertise will conduct chart audits and clinician staff, and patient interviews. Provider knowledge, attitudes, and practices will be quantified about 1) vaccine indications, missed opportunities, and invalid contra- indications, 2) disease severity, vaccine efficacy, and adverse reactions, 3) vaccine reimbursement, 4) influence of peers, experts, and patients, 5) vaccine litigation, 6) use of systems that enhance immunization, such as reminder/tracking systems, 7) barriers to office systems, 8) office operations, core values and openness to change, and 9) personal vaccination status. Patient attitudes and beliefs will be quantified using the theory of reasoned action. The relative contributions of patient beliefs, provider beliefs and office systems will be quantified and used to develop a validated questionnaire for the second phase. In the second phase, a more generalizable, national sample of primary care physician (family physicians, general practitioners, general internists, and geriatricians) will be interviewed by telephone about barriers to immunizations and to proactive systems, over-sampling those practicing in areas with high proportions of minorities. This project will furnish relevant, up-to-date to enhance policy planning, practice management and medical education.